National survey of emergency dept management of self-harm highlights successes, room for improvement

COLUMBUS, Ohio - Approximately half a million patients in the United States arrive in emergency departments (EDs) after deliberate self-harm annually. In the short term following the ED visit, these patients are at high risk for repeated self-harm and suicide.

In a study published March 13 in JAMA Psychiatry, researchers at Nationwide Children's Hospital describe the results of a national survey to evaluate how frequently evidence-based management practices are used in EDs when treating patients who present for self-harm.

"The emergency department plays a critical role in treating not only the physical injury but the behavioral health concerns that led to self-harm," says Jeff Bridge, PhD, director of the Center for Suicide Research and Prevention in The Research Institute at Nationwide Children's, and lead author on the study. "Improving their emergency care is a key focus of national strategies to reduce the suicide rate, but we don't know all that much about ED management of self-harm."

The survey was mailed to a random sample of 665 ED nursing directors among 2,228 hospitals with five or more self-harm visits in the prior year. Most of the EDs sampled were urban, non-teaching hospitals with high mental health staffing.

Overall, the EDs regularly provided five of 10 specified self-harm management practices. EDs most commonly assessed for current and past suicidal thoughts/behaviors and access to lethal means. In fact, EDs assessed the first two more than 90 percent of the time. However, providing elements of safety planning varied widely, with only two of six elements provided more than half the time.

Components of a good safety plan include an individualized plan to restrict access to lethal means, employing internal coping strategies and accessing available social supports and activities.

"Safety plans are essential to the wellbeing of patients who are at risk for experiencing a mental health crisis," adds Dr. Bridge.

Among the hospitals surveyed, patients in the ED as a result of self-harm were often (79 percent) given a list of professionals or agencies to contact in a crisis, and just over half (52 percent) of patients received education about recognizing the warning signs of suicide. Only 15 percent routinely provided all the recommended safety planning elements.

"Emerging evidence suggests that safety planning in combination with structured telephone follow up can significantly reduce suicidal behaviors after ED discharge," Dr. Bridge says. "This is a specific area where quality improvement efforts in the ED management of self-harm could have an important impact on improving patient outcomes."

The study authors say that future research should evaluate specific aspects of ED interventions for deliberate self-harm and their likelihood to reduce the risk of repeated self-harm and suicide.

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Study co-authors are affiliated with The Ohio State University, Columbia University, University of Pennsylvania, and City University of New York.

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